Diagnosis burnout: Acute staffing shortages weigh on nurses who stay on the job

Oct. 24—Most days when he gets home from work, after he sheds his personal protective equipment and washes his hands one last time, Rich Gilbert finds himself reflexively retreating from his family.

Not because he's worried about spreading COVID-19, necessarily, but because he doesn't want to transfer the stress of his job to his loved ones.

"I'm exhausted, and a little angry, I guess," said Gilbert, 57, who works as a nurse and unit manager at a Portland-area long-term care facility. "And I try not to take it out at home, but boy it's getting hard. So I tend to isolate. ... Now, I feel like I don't have much of a home life anymore."

Eighteen-plus months of pandemic has created a situation that can only be characterized as untenable for many nursing home workers like Gilbert, and those in other health care fields as well. Some nursing homes have closed in recent weeks or have threatened to do so because of staffing shortages. Some have cut back on the number of residents they can serve or halted new admissions. And some have piled on work, out of sheer necessity, to the employees who have stayed.

For Gilbert, his biggest fear is that continued loss of staff will jeopardize care for the 60 or so residents who live there. Thankfully, that hasn't happened yet, although a new COVID-19 outbreak that is ravaging the facility has added another layer of stress. He's coming in early to handle all the blood draws that used to be done by an outside agency, and he's staying late to help dispense medication and even deliver laundry to the machines. He dreads the weekends because he fears he'll be called in to help and doesn't want to live with the guilt of saying no.

"We're all doing things that are not our jobs," he said. "We're trying to make things work as best we can, but I do worry that the health of residents is being compromised."

Gilbert spoke candidly about the stress of being a health care worker in a long-term care facility on the condition that his employer not be identified. He said he doesn't want his facility unfairly targeted for challenges that exist industry-wide and he also wants to protect the privacy of residents there.

The Portland Press Herald/Maine Sunday Telegram verified his employment and the details he shared from other employees and a supervisor. The facility is highly rated by the U.S. Centers for Medicare and Medicaid Services and had no serious deficiencies in its most recent federal inspections.

One of Gilbert's co-workers, Nikki Mowatt, said most people she knows in the field are like Gilbert, carrying some level of stress and wondering if they'd be better off in another field.

Some nursing home administrators have warned that the state's COVID-19 vaccine mandate for all health care workers to be vaccinated by Oct. 29 or they could be fired is contributing to employee shortages, although that's hardly the only factor. Meanwhile, older residents who might be thinking about moving to a long-term care facility are having to wait.

"In 20 years of working in Maine, this is the first time I've seen facilities limit their admissions," said Dr. Jabbar Fazeli, medical director of Durgin Pines Nursing Homes in York County.

The Mills administration announced last month that it will distribute $146 million in funding to congregate living facilities and hospitals to support both workforce recruitment and retention. It's a recognition that the problem has reached a crisis level, but the money has not had an immediate impact.

"I think it's really important that we acknowledge the toll of the pandemic on caregivers," said Angela Westhoff, executive director of the Maine Health Care Association, which represents nursing homes and other long-term care facilities. "I think by nature, these workers are selfless and giving of their time, but it has been both physically and emotionally draining."

John Orestis, president and CEO of North Country Associates, which owns or manages 26 facilities and is the state's largest long-term care provider, said workforce challenges have been growing for years and that has added stress to those who are still left.

The jobs are hard, and the pay hasn't always been commensurate, especially in places that rely heavily on Medicare and Medicaid reimbursement, which many do. With many other employment fields also seeing massive shortages, prospective workers can be selective.

"I wouldn't put it all on the pandemic," Orestis said. "But it's certainly more difficult now. It feels like we're competing against ourselves."


Gilbert has a thick frame and slightly overgrown goatee that doesn't quite match his gentle personality. He's been a nurse for 10 years and has worked at his current job for the last three.

His facility avoided any major COVID-19 outbreaks last year, in part he said because it shut down weeks before the virus reached Maine due to a norovirus scare. Most workers were committed to staying in their jobs.

By the spring of 2021, though, he started to notice a shift.

"People were just leaving, and there was nobody applying for jobs to replace them," Gilbert said. "Since then, it's only gotten worse."

Pandemic fatigue has touched everyone, but the relentlessness of working in health care and the life-or-death stakes have created a high level of burnout. A national survey of 1,000 health care workers last month by Morning Consult revealed that 18 percent have left their job during the COVID-19 pandemic and another 12 percent were fired. Among those who have stayed, 31 percent of those surveyed said they have considered leaving.

And a recent survey by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) found that 86 percent of nursing homes and 77 percent of assisted living providers say their workforce situation has gotten worse in just a few months.

Fazeli said the workforce shortage isn't confined to nurses. It's CNAs, housekeepers, kitchen staff.

He said one thing that isn't often mentioned is the impact of foreign workers, who have been restricted from coming to Maine during much of the pandemic. Those workers often worked in hospitality, and those jobs are now being filled by locals. That means more jobs in health care facilities are going unfilled.

"This has boiled under the surface for a while," Fazeli said. "I remember last year when I brought up staffing issues, no one wanted to talk about it. Now it has kind of tipped over."

It's not just nursing homes either. Central Maine Medical Center in Lewiston recently took the extraordinary step of suspending pediatric and trauma admissions due to "acute nursing staffing shortages in key areas." York Hospital also announced last week that it was temporarily halting emergency care because of staffing problems.

Agencies that provide care for adults with intellectual disabilities and substance use disorder have also said the workforce shortage is at a critical point and it's affecting the level of care for vulnerable populations.

Gilbert said many of his co-workers who have stayed are older and have their own physical limitations. Not only are people leaving because of burnout and stress, some are just aging into retirement. There really isn't that much time between when these employees leave the workforce and when some of them might need beds in the facilities where they once worked.

Many homes are relying on temporary or traveling nurses and certified nursing assistants just to get by, but even that has limitations.

So Gilbert keeps showing up each day.

Most mornings, he's there early drawing blood because he's one of the staff members who can do it. They used to have an outside agency come in, but that's no longer the case.

At mealtimes, many of the residents — especially those with dementia — need help eating. That task, which used to be carried out by CNAs, is now left to folks like Gilbert.

He said he and his co-workers try hard to hide their stress from residents. Some cry in the breakroom.

"The residents can sense it, though," he said. "They are all isolated in their rooms. Activities have been canceled. There is limited visitation. A lot of depression has settled in."

Kelley Gilbert, Rich's wife, said she's seen the stress mount in her husband in recent months.

"There are days when he comes home, has dinner, and goes to bed because he is so mentally exhausted he has to rest," she said. "There was a period of time when it felt like the pandemic was getting better and cases were down, and my husband could start to relax at home. We started projects to improve our home and fix up our backyard and life felt more normal. That changed with the delta variant."

Kelley Gilbert said their family sacrificed a lot when her husband attended nursing school and she'd hate to see him leave because he worked so hard and because he's good at it.

"So many health care workers are just burnt out with everything they have had to deal with throughout this pandemic," she said. "The fatigue they feel is not only physical but mental and emotional as well."


Westhoff, with the Maine Health Care Association, said many workers were "drowning in COVID-19" over the winter and spring.

"Then vaccines became available and that was the big pillar of hope that we might get on the other side of this," she said. "What we're seeing now is the realization that this is endemic. There isn't some switch we can flip for this to be over."

The vaccine mandate has been cited by some who have left health care-related fields, and others could be terminated by the end of this month if they fail to comply.

According to the most recent data from the Maine Center for Disease Control and Prevention, 92 percent of hospital workers are fully vaccinated, while 86 percent of nursing home employees have gotten their shots.

The facility Gilbert works in had a vaccination rate of 94 percent as of last month, up from 60 percent in May.

Gilbert said he understand how some workers might balk at a mandate. He wasn't first in line either.

"I was eligible in January but didn't get mine until May," he said, crediting his wife for persuading him.

Mowatt said she, too, knows staff members who left because of the vaccine mandate but doesn't know if they would have left anyway.

She was late to get the vaccine herself because she was pregnant and then because she was breastfeeding and was wary. Experts have said the vaccine poses no risk to pregnant mothers. But when it came time to choose being getting vaccinated or getting fired, she took the shot.

Mowatt, who just returned from 12 weeks of maternity leave, admitted she looked for other jobs during that time. In the end, though, she doesn't want to leave.

"I've been there since 2002. I love it there. I love everything about it," she said. "I just have such a strong connection to the staff members who have stayed and to the residents. They are like family."

Officials have said the vaccine mandate is a small contributing factor. Workers who were already nearing their breaking point may see it as a final straw.

"Ours is a profession that calls out to people who make the decision to work with us with their heart as much as anything else," said Orestis, the nursing home administrator. "But they have to live. They have to support their family."

At Gilbert's facility, nurses make between $26 and $30 per hour, while CNAs make $16 to $20 an hour.

Just as workers have to weigh the financial aspects of staying or leaving, so too do the facilities themselves. The only way for them to make more money is to bring in more residents, but they can't do that if they can't care for them.

Fazeli, the medical director at Durgin Pines, said because new admissions have been halted, many older Mainers are being released from hospitals to their homes, rather than to a rehab facility.

"What that means is: People are staying in an unsafe environment longer. The burden on families increases, as does the risk for elder abuse or neglect," he said.

There are some signs of hope that things may improve.

Nationally, enrollment in nursing programs increased 5.6 percent in 2020 over the previous year, to just over 250,000 students, according to the American Association of Colleges of Nursing. Figures for the current 2021-22 school year won't be available until January, but administrators expect that trend to continue.

And the additional money announced last month by the Mills administration has started to funnel down to long-term care facilities.

"Most of it is aimed at staff retention and recruitment and that's how we'll use it," Orestis said. "And we're happy to have it. Money is never the only solution, but it certainly can help."

Gilbert said his facility is offering pay differential for staff who work certain shifts or with COVID patients.

"Honestly, I would rather give that $5 an hour to a new staff person and have that time with my family," he said. "And to not see people suffering or not come in the next day and find out about all the things that got missed the night before."

Lately, Gilbert measures his days by one somber metric.

"If you go home and nobody died, then you had a good day," he said.